Related Articles

Background

Sustaining integrated care is difficult, in large part because of problems encountered securing the participation of health care and social service professionals and, in particular, general practitioners (GPs).

Purpose

To present an innovative bottom-up and pragmatic strategy used to implement a new integrated care model in France for community-dwelling elderly people with complex needs.

Results

In the first step, a diagnostic study was conducted with face-to-face interviews to gather data on current practices from a sample of health and social stakeholders working with elderly people. In the second step, an integrated care model called Coordination Personnes Agées (COPA) was designed by the same major stakeholders in order to define its detailed characteristics based on the local context. In the third step, the model was implemented in two phases: adoption and maintenance. This strategy was carried out by a continuous and flexible leadership throughout the process, initially with a mixed leadership (clinician and researcher) followed by a double one (clinician and managers of services) in the implementation phase.

Conclusion

The implementation of this bottom-up and pragmatic strategy relied on establishing a collaborative dynamic among health and social stakeholders. This enhanced their involvement throughout the implementation phase, particularly among the GPs, and allowed them to support the change practices and services arrangements.

Care of the aged necessitates a functional diagnosis, with which physicians have little familiarity. The author reviews the principles of autonomy and dependence, applying them to the health care context. He proposes a method of sifting the necessary factors in measuring functional autonomy in elderly people.

Introduction

The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. In the PRISMA-France study, we qualitatively studied the implementation process of this model in French settings.

Method

Our analyses were based on in-depth interviews, meeting observations and the documentation produced.

Results

We adapted the implementation scale inherent to the PRISMA model to fit the French context and, using this scale, were able to appreciate a 15% progression of implementation, from 5% to 20%, in the first 18 months of the study. The factors that contributed to this rate of progression are of three main types. To begin with, contextual factors intrinsic to the French setting complexified the incorporation of integration into the public policy agenda and the means to achieve this feat. Secondly, factors related to the background of the concerned managers and professionals were identified. Thirdly, factors related to the particularities of the PRISMA-Experiment's governance were noted. Our experience leads to consider time as the answer to these hindering contextual, professional and governance issues.

Conclusion

These observations hold an important strategic value in a time where a wider integration experimentation is planned by the ‘plan-Alzheimer’ in France.

Context

The Basque Department of Health released in 2010 the “Strategy for tackling the challenge of chronicity in the Basque Country”. One of its five priority policies is contributing to the continuity of care for chronic patients. A key strategic project is the development of new integration initiatives and pilots projects in the public Basque Health System. Five different integration projects are already in place, with the Bidasoa Integrated Healthcare Organisation as the flagship project.

Aim

The creation of the Bidasoa Integrated Healthcare Organisation as a public brand new organisation in January 2011 aims at integrating three primary care centres and their regional hospital of reference, covering a total population of 86,235 citizens.

Case description

The Bidasoa integration process is characterised by its shared leadership, with converging top-down and bottom-up initiatives, and collaboration between top-management and clinicians. The initiatives for integration are operating simultaneously at different levels: strategic (integrated strategic plan), financial (common budget and capitation payment), managerial (integrated clinical management agreements), processes (integrated care pathways, development of transitional care nursing, creation of polipathology unit), tools (stratification of the population, unification of electronic health record), and research (development of action-research pilots).

Background

Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.

Methods

We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.

Results

The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.

Conclusion

A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.

Introduction

The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. The PRISMA France study aims to investigate the implementation of this model, which relies on the establishment of advisory boards at institutional, organisational and professional levels of decision-making, in France. These boards are guided by whole systems thinking and function in a joined-up, co-ordinated manner.

Method

A qualitative approach was adopted to study the model's implementation. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings and administrative documentations. Validity was insured by triangulation methods and content saturation.

Results

Our analyses revealed the complexity, instability and fragmentation of the institutional governance of publics policies for elderly people. The ‘path dependence’ to the Bismarckian system and the incomplete reforms of gerontological policies generate a cohabitation of three concurrent policies (national, regional and local) and a juxtaposition of two institutional systems (health and social care policy and social welfare). In such a context, no institution possesses sufficient authority to determine gerontological policy.

Conclusion

In the light of these analyse, the particularly complex and time-consuming implementation of the PRISMA model in France can be better understood.

Purpose

To share experiences by discussing the necessity, the challenges and the used (implementation) strategies on integrated care.

Context

Integrated care and chronic care by SGE will be described. SGE delivers with 260 professionals integrated primary healthcare, based on protocols, standards and disease programs for 80,000 people. There is a formalized and structural cooperation with hospitals, their specialists, social services and other organizations.

Because half of all the people with chronic illness have multiple conditions, SGE has taken interest in changing the management of diseases, such as heart failure, COPD, diabetes, depression. Deficiencies in current management and the transformation of health care from reactive to proactive are discussed. Approaches, methods and tools used by SGE are focused on. For example: the transition with the Chronic Care Model. This model summarizes the basic elements for improving health care in health systems at the community, organizations, practice and patient levels. Issues like implementation of chronic care programs and how SGE cooperates with the Maastricht University for evaluating outcomes of effectiveness of integrated care by SGE come up for discussion.

Data source

1. Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic applications and implications, a discussion paper. Int J Integr Care 2002 Oct–Dec;2:e12.

2. Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv 2001;27:63–80.

3. Pater L, Dubbeldam S, Verweijen M. Implementeren, het speelveld in de praktijk. Lemma 2005.

4. Grol R, Wensing M, Eccles M. Improving patient care, the implementation of change in clinical practice. Butterworth-Heinemann 2004.

Preliminary conclusion

The multi-problem patients do need a change in health systems. Despite everything already done, there is still a long way to go. Local, national and international collaborations and networks therefore are a must.

Discussion

Is the Chronic Care Model the model to make integrated care for frail elderly, patients with chronic care or long term care needs possible? The do's and the dont's in implementing integrated care.

Introduction

Societies today are very complex. Effective and successful implementation of care policies is needed. The concept of stakeholder approach is about creating tools and instruments to organise the communication between all parties involved.

Aim

EASPD organised in 2006 the conference ‘ageing and disability—disabled people are ageing, ageing people are getting disabled’ in Austria. For the first time organisations from the care sector for ageing people and from the disability sector were working together to discuss their concepts and their experience and to develop strategies. In this conference main results of this cooperation will be analysed.

Results

The care sector for elderly people in many countries is now facing the same problems as the disability sector 20 years ago: services are mainly medical oriented, the main solutions are care homes, services are social not right driven, the choice for individuals is very limited, … . We will come up with some suggestions to bridge the gap between the disability sector and the care sector in order to equalise the opportunities for elderly people with care needs.

Background

Frail elderly people need an integrated and coordinated care. The two-armed study "Continuum of care for frail elderly people" is a multi-professional and multidimensional intervention for frail community-dwelling elderly people. It was designed to evaluate whether the intervention programme for frail elderly people can reduce the number of visits to hospital, increase satisfaction with health and social care and maintain functional abilities. The implementation process is explored and analysed along with the intervention. In this paper we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants.

Methods/design

The study is a randomised two-armed controlled trial with follow ups at 3, 6 and 12 months. The study group includes elderly people who sought care at the emergency ward and discharged to their own homes in the community. Inclusion criteria were 80 years and older or 65 to 79 years with at least one chronic disease and dependent in at least one activity of daily living. Exclusion criteria were acute severely illness with an immediate need of the assessment and treatment by a physician, severe cognitive impairment and palliative care. The intention was that the study group should comprise a representative sample of frail elderly people at a high risk of future health care consumption. The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process.

Discussion

The design of the study, the randomisation procedure and the protocol meetings were intended to ensure the quality of the study. The implementation of the intervention programme is followed and analysed throughout the whole study, which enables us to generate knowledge on the process of implementing complex interventions. The intervention contributes to early recognition of both the elderly peoples' needs of information, care and rehabilitation and of informal caregivers' need of support and information. This study is expected to show positive effects on frail elderly peoples' health care consumption, functional abilities and satisfaction with health and social care.

Trial registration

ClinicalTrials.gov: NCT01260493

Background

With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.

Methods/design

The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.

Discussion

The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.

Trial registration

The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797

The general approach to prevention in elderly patients differs from that for younger patients. In the elderly, most of the preventive activites performed by family physicians are tertiary. Prevention and cure of disease often overlap. The major health problem in elderly patients is the development of progressive incapacity. The evaluation of risk factors for this condition is the principal purpose of the periodic health examination of these patients. This article summarizes the principal recommendations for the periodic health examination of the elderly and discusses barriers to their implementation.

Introduction

The PRISMA France pilot project is ongoing since 2006. This project aims to implement an integrated services delivery (ISD) for elderly people, based on the PRISMA methodology. The experimentation is coupled with an implementation study to identify factors that facilitate and hinder the implementation. The fragmentation of public authorities represents one of the first barriers identified.

In 2009, a large-scale institutional reform has been initiated. It consists of merging various structures having strategic authorities on medical and social care within a single entity: the Health Regional Agencies (HRA). One could anticipate that this reform should facilitate the implementation of ISD.

Aims

To analyze the influence of institutional reforms on a pilot program aiming to implement an ISD. In the framework of our qualitative study we analyze the way the actors conceive the HRA.

Conclusions

The potential to facilitate ISD of the HRA has been identified. It is hope that they should reduce the institutional fragmentation. Nonetheless, the link between these agencies and the implementation of ISD in the pilot project was rarely made.

The extent of institutional change is bought into question by the past of the French system of social welfare.

This article reports the development of our research interests in the field of clinical practice in gerontology, in particular with people suffering from depression during the last five years. It summarizes the progression of our work in four domains: the coping strategies of elderly people with respect to depression, the assessment of depressive symptomatology, the psychotherapy with elderly people who are depressed (in particular the cognitive-behavioral intervention in groups), and the preparation of elderly people to the psychotherapeutic intervention. The article ends with some suggestions for research and clinical practice.

Introduction

The Netherlands Organisation of Health Research and Development (ZonMw) has launched the ambitious National Care for the Elderly Programme to improve care and support for frail elderly persons. This four years programme (2008–2011) is initiated by the Ministry of Health, Welfare and Sport. The budget is 80 million euro.

Description

The programme consists of three steps. First, regional networks were formed consisting of all parties that can contribute to the organisation of care and support for frail elderly persons. Second, innovative experiments were formed within these networks. These experiments focus on a reorganisation and integration of care and support and are formally evaluated. They should lead to added value for elderly people, in terms of greater self-reliance, better retention of function, and reduced care use and treatment burden. The third step is dissemination and implementation of knowledge.

Conclusions

Eight networks are formed and continue to grow. These networks developed 13 experiments on the following topics: screening of frailty, reactivation after hospitalisation, improvement of primary care, integrated care, and new information systems. More experiments will follow.

Discussion

We aim for better integrated care and added value for frail elderly persons through formation of networks and experiments. Whether this approach works is still to be tested.

A survey was conducted among 160 persons aged 64 year or more in Montreal who were receiving home care. They answered at home a questionnaire on their use of health care services and drugs, and showed the interviewer all the drugs they were taking. In comparison with similar data from elsewhere, the use of health care services (an average of 8.0 encounters with a physician per person per year) and of drugs (an average of 5.3 per person) by this group seems high. Perhaps this group of people was obviously sicker than others of the same age, but this remains to be shown. Moreover, despite the reported frequency of health problems, it is uncertain whether such use of services and drugs was necessary. The question is raised whether the home care system is doing for the patient what it was intended to do.

With the increasing expenditure on health care programs for seniors, there is an urgent need to evaluate such programs. The Measurement Iterative Loop is a tool that can provide both health administrators and health researchers with a method of evaluation of existing programs and identification of gaps in knowledge, and forms a rational basis for health-care policy decisions. In this article, the Loop is applied to one common problem of the elderly: dementia.

Treating agitation in elderly people is a complex process. Faced with a paucity of empirical information, clinicians tend to adopt a therapeutic approach based on their clinical evaluation. This article offers a rational approach that will help physicians to better understand, evaluate, and treat agitation.

Introduction

Montenegro, a newly independent Balkan state with a population of 650,000, has a health care reform programme supported by the World Bank. This paper describes planning for integrated elderly and palliative care.

Description

The current service is provided only through a single long-stay hospital, which has institutionalised patients and limited facilities. Broad estimates were made of current financial expenditures on elderly care. A consultation was undertaken with stakeholders to propose an integrated system linking primary and secondary health care with social care; supporting people to live, and die well, at home; developing local nursing homes for people with higher dependency; creating specialised elderly-care services within hospitals; and providing good end-of-life care for all who need it. Effectiveness may be measured by monitoring patient and carers’ perceptions of the care experience.

Discussion

Changes in provision of elderly care may be achieved through redirection of existing resources, but the health and social care services also need to enhance elderly care budgets. The challenges for implementation include management skills, engaging professionals and political commitment.

Conclusion

Middle-income countries such as Montenegro can develop elderly and palliative care services through redirection of existing finance if accompanied by new service objectives, staff skills and integrated management.

Introduction

The health care system is in transition. Integrated cares solutions are prominent and even forced by health care policy. But how can we understand the needs of different stakeholders in this system? Why do they still not act effectively and efficiently together? A closer look, using the structuration theory of Anthony Giddens, may be helpful.

Theory

The theory of structuration enables people to explain social interactions. As this is a matter of fact, the health care system was analyzed by the author in her habilitation thesis. The focus of the study laid on the effective and efficient care of the very old people in Germany. The structuration theory was presented, and as an example of practical translation of the theory, the implementation of the ‘Pflegestützpunkte’ (service point for care) was described.

Practice

Giddens' structuration theory is on the one hand complex in theory, and simple on the other hand in practice. Choosing the paradigm may be helpful to explain the motivation of the different stakeholders in the health care system. It would be necessary to create a suitable questionnaire, to get deeper insight in how the different actors in the system act and react. Such a questionnaire should be based on Giddens' theory. The following three dimensions are needed: structure (including domination, legitimation, and signification), interaction (including power, sanctioning, and communication) and modality/duality (including instruments of power, norms and interpretation).

As ambulatory care practices face increasing pressure to implement electronic health records (EHRs), there is a growing need to determine the essential elements of a successful implementation strategy. HealthTexas Provider Network is in the process of implementing an EHR system comprising GE Centricity Physician Office–EMR 2005, Clinical Content Consultants (now part of GE), and Kryptiq Secure Messaging throughout all 88 practices in the Dallas–Fort Worth area and is hoping to extend the system to other practices affiliated with Baylor Health Care System as well. We describe the preimplementation clinical process redesign and quality improvement training that has been conducted networkwide in preparation for the introduction of the EHR, as well as the specific steps taken to prepare and train clinic staff for the integration of the EHR into daily workflows. The first pilot site, Family Medical Center at North Garland, implemented the system in May 2006. Based on both the positive aspects of this experience and the challenges we encountered, we identified 20 essential elements for successful implementation in the areas of site selection, implementation strategy, staff education and preparation, team project management, content, hardware and software, and workflow process. Broadly, we determined that 1) a pilot site's understanding of and willingness to work within the fluid nature of the implementation process during what is essentially a testing phase is a key ingredient in achieving success at the pilot site and in improving the process for later sites; 2) input from and representation of viewpoints of all types of EHR users during preimplementation decision making enables customization of the system and sufficient preplanning to ensure minimal workflow disruptions during and after implementation; and 3) a high level of technical and training support during the early days of implementation is invaluable.

Introduction

There is a need for integrated care and smooth collaboration between care-providing organisations and professions to create a continuum of care for frail older people. However, collaboration between organisations and professions is often problematic. The aim of this study was to examine the process of implementing a new continuum of care model in a complex organisational context, and illuminate some of the challenges involved. The introduced model strived to connect three organisations responsible for delivering health and social care to older people: the regional hospital, primary health care and municipal eldercare.

Methods

The actions of the actors involved in the process of implementing the model were understood to be shaped by the actors' understanding, commitment and ability. This article is based on 44 qualitative interviews performed on four occasions with 26 key actors at three organisational levels within these three organisations.

Results and conclusions

The results point to the importance of paying regard to the different cultures of the organisations when implementing a new model. The role of upper management emerged as very important. Furthermore, to be accepted, the model has to be experienced as effectively dealing with real problems in the everyday practice of the actors in the organisations, from the bottom to the top.

Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.

Introduction

Demographic ageing is one of the major challenges for governments in developed countries because older people are the main users of health and social care services. More joined-up, partnership approaches supported by information and communications technologies (ICTs) have become key to managing these demands. This article discusses recent developments towards integrated care in the context of one of the arenas in which integration is being attempted, the Single Assessment Process (SAP) to support the care for older people in England. It draws upon accounts of local SAP implementations in order to assess and reflect upon some of the successes and limitations of service integration enabled by ICTs.

Description of care practice

At the Department of Health in England, policy and strategy are directed at the integration of services through a ‘whole systems’ approach, with services that are interdependent upon one another and organised around the person that uses them. The Single Assessment Processes (SAP) is an instance of inter-organisational and cross-sectoral sharing of information intended to improve communication and coordination amongst professions and agencies and so support more integrated care. The aim of SAP is to ensure that older people receive appropriate, effective and timely responses to their health and social care needs and that professionals do not duplicate each others efforts. This article examines examples from two programmes of work within the context of SAP in England: one with the direction coming from local government social services, the other where the momentum is coming from the National Health Service (NHS).

Conclusion and discussion

Both examples show that the policy and practice of ICT-supported integration continues to represent a significant challenge. Although the notion of integrated care underpinned by ICT-enabled information sharing is persuasive, it has limitations in practice. The notion of an ‘open systems’ approach is proposed as an alternative way of improving communication and coordination across the domains of health and social care.

Background

Chronic diseases represent a major challenge for health care and social services. A number of people with chronic diseases require more services due to characteristics that increase their vulnerability. Given the burden of increasingly vulnerable patients on primary care, a pragmatic intervention in four Family Medicine Groups (primary care practices in Quebec, Canada) has been proposed for individuals with chronic diseases (diabetes, cardiovascular diseases, respiratory diseases, musculoskeletal diseases and/or chronic pain) who are frequent users of hospital services. The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program. The goals of this study are to: (1) analyze the implementation of the intervention in the participating practices in order to determine how the various contexts have influenced the implementation and the observed effects; (2) evaluate the proximal (self-efficacy, self-management, health habits, activation and psychological distress) and intermediate (empowerment, quality of life and health care use) effects of the intervention on patients; (3) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention.

Methods/Design

The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders (Family Medicine Group and health centre management, Family Medicine Group practitioners, patients and their families, health centre or community partners). The data will be obtained through individual and group interviews, project documentation reviews and by documenting the intervention. Evaluation of the effects on patients will be based on a pragmatic randomized before-after experimental design with a delayed intervention control group (six months). Economic analysis will include cost-effectiveness and cost-benefit analysis.

Discussion

The integration of a case management intervention delivered by nurses and self-management group support into primary care practices has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care. Decision-makers, managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practices in the region and elsewhere.

Trial Registration

NCT01719991

Introduction

Health and social care collaboration is currently a key feature of improvement efforts internationally. Moreover, leadership is increasingly considered an important driver in terms of organisational performance, in particular in relation to the implementation of policy designed to solve the wicked issues of society. Yet, despite leadership being viewed as an essential component of integrative public sector performance, there is relatively little thoughtful work analysing the relationship between the two sets of ideas. Leadership in collaborative settings is simultaneously represented as being both the same, and yet different, to these roles in more traditional settings. What this means in practice is that much of the literature appears somewhat at best platitudinous and at worst confused—posing practical difficulties for leaders and managers of collaborations who are looking for evidence or guidance on how to enact leadership.

Aims and objectives

This paper examines the literature and asks how different leadership in inter-agency settings is from more ‘traditional’ settings, before going on to map out lessons which may be useful for leaders and managers to draw upon in more effectively navigating this difficult terrain.

Methods

This research is based on an extensive review of the literature surrounding leadership, collaboration and broader theories of networks.

Results

The paper finds that this distinction is overstated; there are also significant overlaps in the types of tasks and challenges that both sets of leaders and managers will face and these should not be underestimated.

Conclusions

This has clear implications for training and development of these individuals where understanding of the contexts for and nature of partnerships—and thus the sensemaking and performance that may be most effective—may be as important as the skills and attributes themselves.